Healthcare Provider Details

I. General information

NPI: 1710243621
Provider Name (Legal Business Name): MICHELE A GORTAKOWSKI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2012
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 MAIN ST FL 3
SPRINGFIELD MA
01107-1112
US

IV. Provider business mailing address

280 CHESTNUT ST 2ND FLOOR
SPRINGFIELD MA
01199-1001
US

V. Phone/Fax

Practice location:
  • Phone: 413-794-7031
  • Fax: 413-794-7133
Mailing address:
  • Phone: 413-794-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number268474
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number252039
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number268474
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: